molina healthcare of ohio prior authorization (pa) list · molina healthcare of ohio prior...

Molina Healthcare of OhioPrior Authorization (PA) List

All drugs listed on the PA list require prior authorization in order to be covered. This list applies to all Molina Healthcare members, including Covered Families and Children (CFC) and Aged, Blind or Disabled (ABD) members. Molina Healthcare covers all medically-necessary, Medicaid-covered prescription medications available through the traditional fee-for-service Medicaid program but may require prior authorization differently.

Some drugs, mostly injections, must be obtained from Caremark Specialty Pharmacy. After a member’s drug is authorized, the member will be informed that the drug will be shipped to the member from Caremark Specialty Pharmacy.

The PA process is initiated by the prescriber completing a PA form requesting the medication and faxing it to Molina Healthcare at (800) 961-5160. A PA form may be downloaded from the Molina Healthcare of Ohio website at www.MolinaHealthcare.com. The turnaround time for all prior authorization requests is within 24 hours of receiving the request with the exception of weekends and holidays. A fax will be issued to the provider once a decision has been made (both approvals and denials). If you receive a denial on a medication and wish to appeal the decision on the member’s behalf, please call (800) 642-4168 to initiate the appeals process.

Urgent requests for medication may be made by calling the Pharmacy department at (800) 642-4168.

Branded drugs that have a generic equivalent available require PA if the brand is requested. This list does not show all of the brand name drugs that have a generic available.

Brand name medications that have generic equivalents will only be dispensed in generic form unless the prescriber indicates a branded drug is necessary (DAW) and Molina Healthcare prior authorizes the drug.

Step therapy and quantity limit exceptions require prior authorization.

Molina Healthcare’s Pharmacy department is available 8 a.m. to 6 p.m. Monday through Friday by calling (800) 642-4168.

PRIOR AUTHORIZATION CODE: Lower Cost Alternatives = There is another drug that does the same as the Prior Authorized drug and it costs less. The alternative drugs are listed. A member can ask his or her provider if the alternative is right for the member. Step Therapy = The member must have tried another drug before the use of the drug with Prior Authorization. Clinical Review = These requests must go through clinical review. There are certain medical records, laboratory tests or certain diseases listed in order to get this medication. Duration of Therapy Limit = There is no initial Prior Authorization required. PA is only required after a certain period of time.

14076928OH0419

14076928 2019 OH Medicaid TANF Form Provider Pharmacy PA List.indd 1 5/15/2019 4:11:01 PM

DRUG NAME PA CODE ALTERNATIVE DRUG / CRITERIA

8-MOP 10 MG CAPSULE CLINICAL REVIEW REQUIRES CLINICAL REVIEWABILIFY SOLUTION CLINICAL REVIEW REQUIRES CLINICAL REVIEWABILIFY DISCMELT CLINICAL REVIEW REQUIRES CLINICAL REVIEWABILIFY DISCMELT TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWABILIFY TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWABSORICA CAP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWABSTRAL TAB SUBLING CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,

MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ACANYA GEL PUMP LOWER COST ALTERNATIVES CLINDAMYCIN, BENZOYL PEROXIDEACIPHEX LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE,

NEXIUM OTCACTEMRA SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ACTIMMUNE 2 MILLION UNIT VI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ACTIQ LOZENGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWACTIVE OB SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONACTIVELLA TABLET LOWER COST ALTERNATIVES USE FORMULARY ALTERNATIVESACTONEL TABLET LOWER COST ALTERNATIVES GENERIC ALENDRONATEACTONEL WITH CALCIUM TABLET LOWER COST ALTERNATIVES GENERIC ALENDRONATE PLUS CALCIUMACTOPLUS MET XR LOWER COST ALTERNATIVES ACTOPLUS METACUVAIL 0.45% OPHTH SOLUTIO LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONACZONE LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONADAPALENE 0.1% CREAM, GEL 0.3%, LOTION 0.1%

LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE, CLINDAMYCIN SOLUTION

ADCETRIS INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ADCIRCA 20 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ADEMPAS TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ADRENACLICK INJ LOWER COST ALTERNATIVES USE EPI-PEN, EPI PEN JRADOXA TABLET LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAPADOXA PAK 1-150 MG TABLET LOWER COST ALTERNATIVES DOXYCYCLINE ADVAIR DISKUS LOWER COST ALTERNATIVE AIRDUO RESPICLICKADVAIR HFA LOWER COST ALTERNATIVE AIRDUO RESPICLICKADVATE 1,201-1,800 UNITS VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWADVATE 1,801-2,400 UNITS VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWADVATE 2,400-3,600 UNITS VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWADVATE 200-400 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEW

Effective April 1, 2019

Molina Healthcare of OhioPrior Authorization (PA) List



ADVATE 401-800 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWADVATE 801-1,200 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWADVICOR TABLETS LOWER COST ALTERNATIVES NIACIN PLUS SIMVASTATINADVIL 200 MG LIQUI-GEL CAPS LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACADZENYS XR ODT LOWER COST ALTERNATIVES GENERIC ADDERALL XR CAPSULESAFINITOR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AIRAVITE TABLET LOWER COST ALTERNATIVES FOLIC ACIDAFREZZA INHALATION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAFSTYLA KIT 250 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWAFSTYLA KIT 500 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWAFSTYLA KIT 1,000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWAFSTYLA KIT 2,000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWAFSTYLA KIT 3,000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWAKNE-MYCIN 2% OINTMENT LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONAKYNZEO CAPSULE LOWER COST ALTERNATIVE ONDANSETRONALAMAST 0.1% DROPS LOWER COST ALTERNATIVES CROMOLYN 4% EYE DROPSALBENZA 200 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWALEVAZOL OINTMENT LOWER COST ALTERNATIVE USE CLOTRIMAZOLEALECENSA CAPSULE CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW,


ALINIA 100 MG/5 ML SUSPENSI LOWER COST ALTERNATIVES ALINIA 500 MG TABLETALLEGRA 30 MG/5 ML SUSPENSI LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEALLEGRA ODT 30 MG TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEALLEGRA-D TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEALLFEN CD TABLET LOWER COST ALTERNATIVES GUAIFENESIN-CODEINE SYRUPALOCRIL 2% OPHTH DROPS LOWER COST ALTERNATIVES CROMOLYN SODIUM 4% OPHTH SOLALOGLIPTIN STEP THERAPY PREQUISITES INCLUDE METFORMIN OR

METFORMIN COMBINATIONS, SULFONYLUREA OR SULFONYLUREA COMBINATIONS

ALOMIDE 0.1% DROPS LOWER COST ALTERNATIVE KETOTIFENALORA LOWER COST ALTERNATIVES GENERIC CLIMARA PATCHALPHAGAN P 0.1% DROPS LOWER COST ALTERNATIVES ALPHAGAN P 0.15% EYE DROPSALPHANATE 1,000-400 UNIT VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPHANATE 1,500-600 UNIT VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPHANATE 250-100 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPHANATE 500-200 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPHANATE/VWF COMPLEX/HUMAN

CLINICAL REVIEW REQUIRES CLINICAL REVIEW

ALPHANINE SD 1,000 UNITS VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPHANINE SD 1,500 UNITS VI CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPHANINE SD 500 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPRAZOLAM ER TABLET LOWER COST ALTERNATIVES ALPRAZOLAM REG. STRENGTH TABLETSALPRAZOLAM ODT LOWER COST ALTERNATIVES ALPRAZOLAM REG. STRENGTH TABLETSALPROLIX 1,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPROLIX 2,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPROLIX 3,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPROLIX 500 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPROLIX INJ 250 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWALPROLIX INJ 4000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEW



ALREX EYE DROPS LOWER COST ALTERNATIVES FLUOROMETHOLONE, PREDNISOLONE ACETATEALTABAX 1% OINTMENT LOWER COST ALTERNATIVES MURIPROCIN CREAM/OINTMENTALTOPREV TABLET LOWER COST ALTERNATIVES SIMVASTATINALVESCO INHALER LOWER COST ALTERNATIVES QVAR, AEROSPAN, ARNUITY ELLIPTAAMINOSYN II 15% IV SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAMITIZA CAPSULE LOWER COST ALTERNATIVES MIRALAX , LACTULOSEAMPYRA ER 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AMRIX ER CAPSULE LOWER COST ALTERNATIVES CYCLOBENZAPRINE TABLETANABAR CAPLET LOWER COST ALTERNATIVES ACETOMINOPHEN PLUS ANTIHISTAMINEANADROL-50 TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWANCOBON LOWER COST ALTERNATIVE FLUCONAZOLE, ITRACONAZOLE, KETOCONAZOLEANDRODERM CLINICAL REVIEW REQUIRES CLINICAL REVIEWANDRODERM PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ANDROGEL ALL STRENGTHS CLINICAL REVIEW REQUIRES CLINICAL REVIEWANDROGEN PRODUCTS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ANGELIQ 0.5 MG-1 MG TABLET LOWER COST ALTERNATIVES USE FORMULARY ALTERNATIVESANTARA 30 MG CAPSULE LOWER COST ALTERNATIVES FENOFIBRATE GENERICANTARA CAPSULE LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGANZEMET TABLET LOWER COST ALTERNATIVES ONDANSETRONAPIDRA LOWER COST ALTERNATIVE NOVOLOGAPLENZIN ER TABLET LOWER COST ALTERNATIVES WELLBUTRIN XLAPOKYN 30 MG/3 ML CARTRIDGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


APTENSIO XR CAPSULE LOWER COST ALTERNATIVE METADATE CD, CONCERTAARANESP INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ARCALYST 220 MG INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ARCAPTA NEOHALER LOWER COST ALTERNATIVES SEREVENT ARICEPT 23 MG TABLET LOWER COST ALTERNATIVES GENERIC DONEPEZIL 20 MGARISTADA ER SUSPENSION CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWARIXTRA SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ARTHROTEC EC LOWER COST ALTERNATIVES DICLOFENAC SODIUM PLUS MISOPROSTOLASTAGRAF XL CAPSULE LOWER COST ALTERNATIVES GENERIC TACROLIMUSATACAND TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORATACAND HCT TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZ, IRBESARTAN-HCTZATELVIA DR 35 MG TABLET LOWER COST ALTERNATIVES GENRIC ALENDRONATEATGAM 50 MG/ML AMPUL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ATRIPLA 600 MG-200 MG-300 MG TABLET

CLINICAL REVIEW USE FORMULARY ALTERNATIVE ATIRETROVIRAL PRODUCTS

AUBAGIO 14 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



AUBAGIO 7 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

AVAIR 100/50 CLINICAL REVIEW REQUIRES CLINICAL REVIEWAVANDAMET TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVANDARYL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVANDIA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVAR CLEANSING PADS LOWER COST ALTERNATIVES SULFACETAMIDE/SULFUR CRM, GEL, LOTION, PADS

GENERICAVAR FOAM LOWER COST ALTERNATIVE SULFACETAMIDE/SULFUR CRM, GEL, LOTION, PADSAVELOX 400 MG TABLET LOWER COST ALTERNATIVES OFLOXACIN, LEVOFLOXACINAVINZA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWAVODART 0.5 MG SOFTGEL LOWER COST ALTERNATIVES FINASTERIDE (PROSCAR)AVONEX ADMIN PACK 30 MCG VL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AXERT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEAXIRON CLINICAL REVIEW REQUIRES CLINICAL REVIEWAZASITE 1% EYE DROPS LOWER COST ALTERNATIVES CIPROFLOXACIN, OFLOXACIN EYE DROPSAZELASTINE 0.05% EYE DROPS LOW COST ALTERNATIVE KETOTIFENAZELEX 20% CREAM LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONAZILECT TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


AZOR TABLET LOWER COST ALTERNATIVES LOSARTAN PLUS AMLODIPINEBANZEL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBEBULIN VH IMMU 200-1,200 U CLINICAL REVIEW REQUIRES CLINICAL REVIEWBECONASE AQ 0.042% SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONEBELBUCA FILM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBELSOMRA TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBENEFIX 250 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWBENEFIX 500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWBENEFIX 1,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWBENEFIX 2,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWBENEFIX INJ 3000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWBENICAR HCT TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZ, IRBESARTAN-HCTZBENICAR TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORBENZACLIN GEL 35 G PUMP LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONBENZAMYCIN LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONBENZEFOAM 5.3% EMOLLIENT FO LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZEFOAM ULTRA 9.8% FOAM LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZIQ 5.25% GEL LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZIQ 5.25% WASH LOWER COST ALTERNATIVES BENZOYL PEROXIDEBENZOYL PEROXIDE 7% WASH LOWER COST ALTERNATIVES BENZOYL PEROXIDEBEPREVE 1.5% EYE DROPS LOWER COST ALTERNATIVES KETOTIFENBESIVANCE 0.6% SUSP LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTHBETASERON 0.3 MG KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,




BETHKIS 300 MG/4 ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

BETHKIS NEB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBEVESPI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBILTRICIDE 600 MG TABLET CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWBLEPHAMIDE EYE DROPS LOWER COST ALTERNATIVES FLUOROMETHOLONE, PREDNISOLONE ACETATEBONIVA 150 MG TABLET LOWER COST ALTERNATIVES GENRIC ALENDRONATEBOSULIF 500 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWB-PLEX TABLET LOWER COST ALTERNATIVES FOLBEE PLUS TABLETBREO ELLIPTA LOWER COST ALTERNATIVE AIRDUO RESPICLICKBREVOXYL COMPLETE PACK LOWER COST ALTERNATIVES BENZOYL PEROXIDEBREVOXYL-4 COMPLETE PACK LOWER COST ALTERNATIVES BENZOYL PEROXIDEBREVOXYL-8 COMPLETE PACK LOWER COST ALTERNATIVES BENZOYL PEROXIDEBRILINTA CLINICAL REVIEW REQUIRES CLINICAL REVIEWBRISDELLE 7.5 MG CAPSULE LOWER COST ALTERNATIVES PAROXETINE TABLETSBRIVIACT SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBRIVIACT TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBROMDAY 0.09% EYE DROPS LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONBROMSITE DROPS LOWER COST ALTERNATIVE KETOROLAC, DICLOFENACBROVANA 15 MCG/2 ML SOLUTIO CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBUNAVAIL FILM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWBUPHENYL POWDER LOWER COST ALTERNATIVES BUPHENYL 500 MG TABLETBUTISOL SODIUM 30 MG/5 ML E LOWER COST ALTERNATIVES PHENOBARBITAL TABLETBUTISOL SODIUM TABLET LOWER COST ALTERNATIVES PHENOBARBITAL TABLETBUTRANS PATCH CLINICAL REVIEW REQUIRES CLINICAL REVIEWBYDUREON 2 MG STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICSBYETTA DOSE PEN INJ LOWER COST ALTERNATIVES VICTOZA OR OZEMPICBYSTOLIC TABLET LOWER COST ALTERNATIVES ATENOLOL, BISOPROLOL, METOPROLOLBYVALSON LOWER COST ALTERNATIVES METOPROLOL ER, BISOPROLOL, ATENOLOL PLUS

VALSARTANCABOMETYX CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW.


CADUET TABLET LOWER COST ALTERNATIVES AMLODIPINE PLUS SIMVASTATINCAMBIA 50 MG POWDER PACKET LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACCANTIL 25 MG TABLET LOWER COST ALTERNATIVES PROPANTHELINE , GLYCOPYRROLATECAPCOF LIQUID LOWER COST ALTERNATIVES PROMETHAZINE VC-CODEINE SYRCAPRELSA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CARBAGLU 200 MG DISPER TABL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCARDURA XL TABLET LOWER COST ALTERNATIVES DOXAZOSIN, TERAZOSIN, TAMSULOSINCARIMUNE NF 12 GM VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CARIMUNE NF 3 GM VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CARIMUNE NF 6 GM VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CARISOPRODOL 350 MG CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCARISOPRODOL CPD-CODEINE TA CLINICAL REVIEW REQUIRES CLINICAL REVIEW



CAVAN-EC SOD DHA VITAMINS LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCAVAN-FOLATE DHA COMBO PACK LOWER COST ALTERNATIVES LACTOCAL-F TABLETCAVAN-HEME OB TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCAYSTON 75 MG INHAL SOLUTIO CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CEDAX TABLETS/SUSPENSION LOWER COST ALTERNATIVES CEFPODOXIME PROXETILCELEBREX CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCENESTIN TABLET LOWER COST ALTERNATIVES ESTRADIOL TABLETSCERDELGA CAP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCEREDASE 80 UNITS/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CEREFOLIN NAC CAPLET LOWER COST ALTERNATIVES FOLIC ACIDCERISA WASH LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONCESAMET 1 MG CAPSULE LOWER COST ALTERNATIVES ONDANSETRONCHANTIX TABLET STEP THERAPY NICOTINE, BUPROPION SRCHENODAL 250 MG TABLET LOWER COST ALTERNATIVES URSODIOL TABLETCHILD DELSYM COUGH+COLD LOWER COST ALTERNATIVES ACETOMINOPHEN, DIPHENHYDRAMINE,

PHENYLEPHRINECHILDREN’S MUCINEX LOWER COST ALTERNATIVES GUAIFENESIN/DEXTROMETHORPHAN SYRUPCHOLBAM CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCIMZIA 200 MG/ML SYRINGE KI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CINRYZE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CIPRO HC OTIC SUSPENSION LOWER COST ALTERNATIVES CETRAXAL, NEOMYCIN/POLYMYXIN B/HYDROCORTISONE

CIPRODEX OTIC LOWER COST ALTERNATIVE CETRAXAL, NEOMYCIN/POLYMYXIN B/HYDROCORTISONE

CITRANATAL 90 DHA PACK LOWER COST ALTERNATIVES COMPLETE-RF PRENATAL TABLETCITRANATAL ASSURE COMBO PAC LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCITRANATAL DHA PACK LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCITRANATAL HARMONY CAPSULE LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMINSCLARAVIS CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCLARIFOAM EF EMOLLIENT FOAM LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONCLARINEX TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINECLARINEX-D TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINECLARIS CLARIFYING WASH LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONCLARITIN REDITABS LOWER COST ALTERNATIVES CETIRIZINE; LORATADINECLIMARA PRO PATCH LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCH, FEMHRTCLINDAMYCIN PHOSPHATE GEL 1% STEP THERAPY DIFFERIN OTC, BENZOYL PEROXIDE, CLINDAMYCIN

SOLUTIONCLINDAMYCIN PHOSPHATE LOTION 1%

STEP THERAPY DIFFERIN OTC, BENZOYL PEROXIDE, CLINDAMYCIN SOLUTION

CLOBEX 0.05% SPRAY LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONECLOBEX 0.05% TOPICAL LOTION LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONECLODAN KIT 0.05% LOWER COST ALTERNATIVE USE TRIAMCINOLONE, BETAMETHASONE, OR

FLUOCINOLONE



CLODERM 0.1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONECLONAZEPAM 0.25 MG ODT LOWER COST ALTERNATIVES CLONAZEPAM ORAL TABLETSCLONAZEPAM DIS TABLET LOWER COST ALTERNATIVES CLONAZEPAM TABLETSCLONIDINE PATCH LOWER COST ALTERNATIVES CLONIDINE TABLETCLORPRES TABLET LOWER COST ALTERNATIVES CHLORTHALIDONE/CLONIDINE TABSCOCET TABLET LOWER COST ALTERNATIVES ACETAMINOPHEN-COD #2 TABLETCOLCHICINE 0.6 MG CAPSULE LOWER COST ALTERNATIVE COLCHICINE TABLETSCOLESTID TABLET/GRANULES PACKET

LOWER COST ALTERNATIVES CHOLESTYRAMINE

COLY-MYCIN S EAR DROPS LOWER COST ALTERNATIVES CORTOMYCIN EAR SUSPENSIONCOMETRIQ 100 MG DAILY-DOSE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


COMETRIQ 140 MG DAILY-DOSE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

COMETRIQ 60 MG DAILY-DOSE P CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

COMPLETE NATAL DHA LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCONCEPT DHA CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONCONEX SOLUTION LOWER COST ALTERNATIVE USE ZYRTEC OTC, CLARITIN OTCCONZIP TABLETS LOWER COST ALTERNATIVES TRAMADOL ERCOPAXONE INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CORLANOR TABLET CLINICAL REVIEW REQUST MUST GO THROUGH CLINICAL REVIEWCOREG CR CAPSULE LOWER COST ALTERNATIVES CARVEDILOLCORTISPORIN CREAM LOWER COST ALTERNATIVES CORTISPORIN OINTCOSENTYX CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


COSOPT PF LOWER COST ALTERNATIVES DORZOLAMIDE/TIMOLOL OPHTH SOLCOTAB AX TABLET LOWER COST ALTERNATIVES DIMETAPP LONG-ACTING COUGHCOTELLIC TABLET CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW,


COVERA-HS ER 180 MG TABLET LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASECOVERA-HS ER 240 MG TABLET LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASECOVERA-HS MG TABLET LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASECRESEMBA CAPSULE LOWER COST ALTERNATIVES FLUCONAZOLE, ITRACONAZOLECRESTOR TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWCRINONE 8% GEL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


CUBICIN 500 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CUTIVATE 0.05% LOTION LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONE

CUVPOSA 1 MG/5 ML SOLUTION LOWER COST ALTERNATIVES GLYCOPYRROLATE TABLETS, GENERIC DONNATALCYCLIVERT LOWER COST ALTERNATIVES MECLIZINE, DIPHENHYDRAMINECYCLOPHOSPHAMIDE 500 MG VIA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCYCLOPHOSPHAMIDE CAP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWCYMBALTA CLINICAL REVIEW REQUIRES CLINICAL REVIEW



CYSTADANE POWDER CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

CYTOGAM 2.5 GM/50 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

DAKLINZA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

DALIRESP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDAYTRANA PATCH LOWER COST ALTERNATIVES METADATE CD CAPSULEDELZICOL DR 400 MG CAPSULE LOWER COST ALTERNATIVES APRISO, ASACOL HDDEMECLOCYCLINE TABLET LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAPDEMSER 250 MG CAPSULE LOWER COST ALTERNATIVES PHENTOLAMINEDENAVIR LOW COST ALTERNATIVE ABREVADEPEN 250 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDEPO-PROVERA PREFILLED SYRINGE

LOWER COST ALTERNATIVES USE MEDROXYPROGESTERONE VIALS

DERMATOP CREAM/ OINTMENT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEDESONATE 0.05% GEL LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEDESOWEN LOT LOWER COST ALTERNATIVES DESONIDE CREAM/OINTMENT WITH GENERIC OTC

CETAPHIL LOTIONDESOXYN 5 MG TABLET LOWER COST ALTERNATIVES AMPHETAMINE, DEXTROAMPHETAMINEDESVENLAFAXINE TAB ER LOWER COST ALTERNATIVES TRIAL OF 2 CITALOPRAM, ESCITALOPRAM,

PAROXETINE, VENLAFAXINE, SERTRALINE, FLUOXETINE, BUPROPION

DETROL LA CAPSULE LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20 MGDEXILANT DR CAPSULE LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE,

NEXIUM OTCDEXRAZOXANE 250 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDEXRAZOXANE 500 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIALYVITE 3,000 TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIALYVITE 5000 TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIALYVITE SUPREME D TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIALYVITE WITH ZINC TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDIATX ZN TABLET LOWER COST ALTERNATIVES DIALYVITE TABLETDICLEGIS DR 10-10 MG TABLET LOWER COST ALTERNATIVES DOXYLAMINE AND PYRIDOXINEDIFICID TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIFIL-G 400 TABLET LOWER COST ALTERNATIVES THEOPHYLLINE TABLETDILATRATE-SR 40 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIOVAN HCT TABLET STEP THERAPY FAILURE ACE INHIBITORDIOVAN TABLET STEP THERAPY FAILURE ACE INHIBITORDIPYRIDAMOLE 5 MG/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWDIVIGEL 0.25 MG GEL PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHDIVIGEL 0.5 MG GEL PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHDIVIGEL 1 MG GEL PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHDORAL 15 MG TABLET LOWER COST ALTERNATIVES ZOLPIDEM, TEMAZEPAMDORYX DR TABLET LOWER COST ALTERNATIVES DOXYCYCLINE 100 MGDOXYCYCLINE HYC DR 75 MG TA LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAPDOXYCYCLINE MONO 75 MG CAPS LOWER COST ALTERNATIVES DOXYCYCLINE MONO 100 MG CAPDRONABINOL CAPSULE CLINICAL REVIEW REQUIRES CLINICAL REVIEWDUAVEE TAB LOWER COST ALTERNATIVE USE FORMULARY ALTERNATIVES WITH

ALENDRONATE



DUET DHA COMPLETE COMBO PAC LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONDUETACT TABLET LOWER COST ALTERNATIVES SULPHONYLUREA PLUS METFORMINDUEXIS LOWER COST ALTERNATIVES IBUPROFEN AND FAMOTIDINEDULERA LOWER COST ALTERNATIVE AIRDUO RESPICLICKDURAFLU TABLET LOWER COST ALTERNATIVES COLD MULTI-SYMPTOM CAPLETDUTOPROL LOWER COST ALTERNATIVES METOPROLOL/HCTZDYLIX 100 MG/15 ML ELIXIR LOWER COST ALTERNATIVES THEOPHYLLINE SOLUTIONDYMISTA 137/50 MCG SPRAY LOWER COST ALTERNATIVES LORATADINE PLUS FLUTICASONE OR FLUNISOLIDEDYMISTA LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE NASAL SPRAYDYNACIRC CR TABLET LOWER COST ALTERNATIVES NIFEDIPINE; AMLODIPINEED CHLORPED D PEDIATRIC DRO LOWER COST ALTERNATIVES RYNATAN PEDIATRIC ORAL SUSPED CYTE F TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLEDARBI 40 LOWER COST ALTERNATIVES LOSARTAN, ACE-INHIBITOREDARBI 80 LOWER COST ALTERNATIVES LOSARTAN, ACE-INHIBITOREDARBYCLOR LOWER COST ALTERNATIVES LOSARTAN-HCTZ, IRBESARTAN-HCTZED-FLEX CAPSULE LOWER COST ALTERNATIVES ACETAMINOPHEN WITH CODEINEEDLUAR 10 MG SL TABLET LOWER COST ALTERNATIVES ZOLPIDEMEDLUAR 5 MG SL TABLET LOWER COST ALTERNATIVES ZOLPIDEMEFFER-K TABLET EFF LOWER COST ALTERNATIVES K-TAB ER 10 MEQ TABLETEFFIENT TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWELESTAT 0.05% EYE DROPS LOWER COST ALTERNATIVES KETOTIFENELESTRIN 0.06% GEL LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHELIDEL 1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEELIQUIS 2.5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWELIQUIS 5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWELOCTATE 250 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE 500 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE 750 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE 1,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE 1,500 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE 2,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE 3,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE INJ 4000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE INJ 5000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWELOCTATE INJ 6000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWEMADINE 0.05% EYE DROPS LOWER COST ALTERNATIVES KETOTIFENEMBEDA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


EMCYT 140 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

EMEND LOWER COST ALTERNATIVES ONDANSETRONEMSAM PATCH LOWER COST ALTERNATIVES SELEGILINE TABLETSENABLEX TABLET LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGENBRACE SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH IRONENBREL INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ENTRESTO TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWENTACAPONE STEP THERAPY PRIOR USE OF CARBIDOPA/LEVODOPAENVARSUS XR TABLET CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW



EPCLUSA TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

EPIDUO FORTE GEL LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE, CLINDAMYCIN SOLUTION

EPIDUO GEL LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE, CLINDAMYCIN SOLUTION

EPLERENONE TABLET LOWER COST ALTERNATIVES SPIRONOLACTONEEPOGEN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ERTACZO 2% CREAM LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMERYGEL TOPICAL GEL LOWER COST ALTERNATIVES USE ERYTHROMYCIN SOLNERYTHROMYCIN GEL 2% LOWER COST ALTERNATIVES ERYTHROMYCIN SOLNESBRIET CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ESCAVITE LQ DROPS LOWER COST ALTERNATIVE USE GENERIC MULTIVITAMIN WITH FLUORIDE AND IRON

ESCITALOPRAM SOL LOWER COST ALTERNATIVE USE ESCITALOPRAM CAPSULESESOMEPRAZOLE DR LOWER COST ALTERNATIVE OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE,

NEXIUM OTCESTRADERM PATCH LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHESTRASORB PACKET LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHESTRING 2 MG VAGINAL RING LOWER COST ALTERNATIVES ESTRACE CREAMEVAMIST 1.53 MG/SPRAY LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHEVEKEO TABLET LOWER COST ALTERNATIVE AMPHETAMINE/DEXTROAMPHETAMINEEVOCLIN 1% FOAM LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONEVZIO INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWEXALGO ER TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWEXELDERM CREAM/SOLUTION LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMEXELON PATCH LOWER COST ALTERNATIVES RIVASTIGMINE, GALANTAMINE/ER TABLETSEXELON 2 MG/ML ORAL SOLUTION LOWER COST ALTERNATIVES RIVASTIGMINE, GALANTAMINE/ER TABLETSEXFORGE TABLET LOWER COST ALTERNATIVES LOSARTAN PLUS AMLODIPINEEXFORGE HCT TAB LOWER COST ALTERNATIVES LOSARTAN-HCTZ PLUS AMLODIPINEEXJADE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


EXONDYS 51 CLINICAL REVIEW REQUIRES CLINICAL REVIEWEXTAVIA 0.3 MG KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


EXTINA 2% FOAM LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMFACTIVE 320 MG TABLET LOWER COST ALTERNATIVES CIPROFLOXACINFABIOR 0.1% FOAM LOWER COST ALTERNATIVES TAZAROTENE CRM/GELFANAPT TABLET LOWER COST ALTERNATIVES RISPERIDONE, GEODON, ZYPREXA, SEROQUELFAZACLO ODT LOWER COST ALTERNATIVES RISPERIDONE, CLOZAPINEFEIBA NF 400-650 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWFEIBA NF 651-1,200 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWFEIBA NF 1,750-3,250 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWFEIBA VH IMMU 400-650 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWFEIBA VH IMMU 651-1,200 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWFEIBA VH IMMU 1,750-3,250 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEW



FEMECAL OB TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONFEMRING 0.05 MG VAGINAL RING LOWER COST ALTERNATIVES ESTRACE CREAMFEMTRACE TABLET LOWER COST ALTERNATIVES ESTRADIOL TABLETSFENTANYL CITRATE BUCCAL TABLETS

CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW

FENTANYL CITRATE OTFC 200 M CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFENTANYL PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFENTORA BUCCAL TABL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFERIVA 21-7 TABLET LOWER COST ALTERNATIVE GENERIC MULTIVITAMIN WITH IRONFERIVA FA CAPSULE LOWER COST ALTERNATIVE GENERIC MULTIVITAMIN WITH IRONFERRALET 90 DUAL-IRON TABLE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFERRAPLUS 90 TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFERREX 28 TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFERRIPROX TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FETZIMA ER CAPSULE LOWER COST ALTERNATIVES VENLAFAXINE ER, SSRIFEXMID 7.5 MG TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLETS, CYCLOBENZAPRINE,

ORPHENADRINE, METHOCARBAMOLFEXOFENADINE 30MG, 60MG HCL TABLET

LOWER COST ALTERNATIVES CETIRIZINE; LORATADINE

FIBRICOR TABLET LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGFINACEA 15% GEL LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONFINACEA PLUS KIT LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONFIORICET-COD 50-300-40-30 C LOWER COST ALTERNATIVES FIORINAL, FIORICETFIRAZYR SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FLAGYL ER 750 MG TABLET LOWER COST ALTERNATIVES METRONIDAZOLE TAB 500 MG & 250 MGFLEBOGAMMA DIF 5% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FLECTOR 1.3% PATCH LOWER COST ALTERNATIVES USE VOLTAREN GELFLO-PRED LOWER COST ALTERNATIVES PREDNISOLONE SOLUTIONFLO-PRED ORAL SUSPENSION LOWER COST ALTERNATIVES PREDNISOLONE ORAL SOLUTIONFLUOR-A-DAY TABLET CHEWABLE LOWER COST ALTERNATIVES FLUORITAB 1 MG TABLET CHEW, EPIFLUR 0.25, 0.5 MGFLUOXETINE 60 MG CAPSULES LOWER COST ALTERNATIVES FLUOXETINE 10 MG, 20 MG CAPSULESFLUOXETINE DR 90 MG CAPSULE LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINEFLUOXETINE HCL TABLET LOWER COST ALTERNATIVES FLUOXETINE 10 MG, 20 MG CAPSULEFLUVOXAMINE XR LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINEFOCALGIN 90 DHA COMBO PACK LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH DHA

FOCALIN XR CAPSULE LOWER COST ALTERNATIVES METADATE CD CAPSULEFOLAST TABLET LOWER COST ALTERNATIVES FOLIC ACIDFOLCAPS TABLET LOWER COST ALTERNATIVES FOLIC ACIDFOLGARD RX TABLET LOWER COST ALTERNATIVES FOLIC ACIDFOLIVANE-EC CALCIUM DHA COM LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONFOLIVANE-OB CAPSULE LOWER COST ALTERNATIVES COMPLETE-RF PRENATAL TABLETFOLIVANE-PRX DHA NF CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONFORTAMET ER TABLET LOWER COST ALTERNATIVES METFORMIN EXTENDED RELEASE 500 MG TABLETSFORTEO 600 MCG/2.4 ML PEN I LOWER COST ALTERNATIVES USE FORMULARY ALTERNATIVE PRODUCTS



FOSAMAX PLUS D LOWER COST ALTERNATIVES GENRIC ALENDRONATE PLUS VIT DFOSRENOL TABLET CHEW LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSFRAGMIN SYRINGE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIAFRESHKOTE EYE DROPS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFROVA 2.5 MG TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEFULYZAQ 125 MG DR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFUMATINIC ER CAPSULE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLFUZEON CONVENIENCE KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


FYCOMPA SUSPENSION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWFYCOMPA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGABLOFEN 10,000 MCG/20 ML V CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGABLOFEN 40,000 MCG/20 ML V CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGABLOFEN 50 MCG/ML SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGAMASTAN S/D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


GAMASTAN S-D VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD LIQUID 10% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD S-D 10 GM VL W/ST CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD S-D 2.5 GM VL W/S CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD S-D 5 G (IGA<1) S CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMMAGARD S-D 5 GM VL W/SET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX 10% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX-C 1 GRAM/10 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX-C 10 GRAM/100 ML VI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX-C 2.5 GRAM/25 ML VI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX-C 20 GRAM/200 ML VI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAMUNEX-C 5 GRAM/50 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



GATTEX VIAL KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GAVILYTE-H AND BISACODYL KI LOWER COST ALTERNATIVE COLYTE, GOLYTELY, NULYTELYGELNIQUE 10% GEL SACHETS LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20 MGGENVOYA TABLET CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWGIAZO 1.1 GM TABLET LOWER COST ALTERNATIVES GENERIC BALSALZIDE, APRISO, ASACOL HDGILENYA 0.5 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


GILOTRIF TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GLATOPA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GLEEVEC TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

GLUMETZA ER TABLET LOWER COST ALTERNATIVES METFORMIN EXTENDED RELEASE 500 MG TABLETSGLYXAMBI TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGRALISE LOWER COST ALTERNATIVES GABAPENTINGRANISETRON TABLETS STEP THERAPY ONDANSETRONGRANIX SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


GRASTEK SL TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWGROWTH HORMONES CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


GUANIDINE HCL 125 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWHALOG CREAM/ OINTMENT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEHARVONI CLINICAL REVIEW REQUIRES CLINICAL REVIEW, MEDICATION MUST BE

OBTAINED FROM SPECIALTY PHARMACYHELIDAC THERAPY LOWER COST ALTERNATIVES PREVPAC PATIENT PACKHELIXATE FS 250UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHELIXATE FS 500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHELIXATE FS 1,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHELIXATE FS 2,000 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHELIXATE FS 3,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHEMANGEOL SOL LOWER COST ALTERNATIVE USE PROPRANOLOL SOLUTIONHEMATOGEN FA SOFTGEL LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMATOGEN SOFTGEL LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMOCYTE PLUS CAPSULE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMOCYTE-F TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLHEMOFIL M 220-400 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHEMOFIL M 401-800 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHEMOFIL M 801-1,700 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHEMOFIL M 1,701-2,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHEPAGAM B VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


HEPAGAM B VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



HIZENTRA 1 GRAM/5 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



HORIZANT ER TABLET LOWER COST ALTERNATIVES GABAPENTINHUMALOG 200 UNITS/ML KWIKPEN CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWHUMALOG CARTRIDGE CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMALOG JUNIOR KWIKPEN CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMALOG KWIKPEN CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMALOG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMATE-P 600 UNIT VWF:RCO CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMATE-P 1,200 UNIT VWF:RCO CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMATE-P 2,400 UNIT VWF:RCO CLINICAL REVIEW REQUIRES CLINICAL REVIEWHUMIRA INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


HYCAMTIN CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HYDROCORT BUTY 0.1% LIPO CR LOWER COST ALTERNATIVES HYDROCORTISONE CREAMHYPERRAB S/D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


HYPERRAB S-D VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HYPERRHO S-D SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

HYSINGLA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

IBRANCE CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

IBUDONE TABLET LOWER COST ALTERNATIVES HYDROCODONE WITH IBUPROFEN TABLETSIDELVION SOL 250 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWIDELVION SOL 500 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWIDELVION SOL 1000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWIDELVION SOL 2000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWILEVRO 0.3% OPHTH DROPS LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONIMBRUVICA 140 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


IMIQUIMOD 5% CREAM PACKET CLINICAL REVIEW REQUIRES CLINICAL REVIEWIMMUNE GLOBULIN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


INCIVEK CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



INCRELEX 40 MG/4 ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

INFANATE BALANCE SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONINFANATE CAP PLUS LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLETINFERGEN VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


INLYTA CLINICAL REVIEW REQUIRES CLINICAL REVIEWINNOHEP 20,000 UNIT/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWINNOPRAN XL CAPSULE LOWER COST ALTERNATIVES GENERIC PROPRANOLOL ERINOVA EASY PAD LOWER COST ALTERNATIVES BENZOYL PEROXIDEINTERMEZZO LOWER COST ALTERNATIVES ZOLPIDEMINTRON A INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


INTUNIV ER TABLET LOWER COST ALTERNATIVES GENERIC GUANFACINEINVEGA ER 1.5 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA ER 3 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA ER 6 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA ER 9 MG TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA TABLET LOWER COST ALTERNATIVES RISPERIDONEINVEGA TRINZA CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWINVOKAMET TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWINVOKAMET XR CLINICAL REVIEW REQUIRES CLINICAL REVIEWINVOKANA TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWIONSYS PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWIOPIDINE 0.5% EYE DROPS LOWER COST ALTERNATIVES ALPHAGAN P 0.15% EYE DROPSIQUIX 1.5% EYE DROPS LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTHIRENKA CAPSULE LOWER COST ALTERNATIVE VENLAFAXINE ER CAPSULESIRESSA 250 MG TABLET CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIA, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ISRADIPINE CAPSULE LOWER COST ALTERNATIVES NIFEDIPINE; AMLODIPINEISTALOL 0.5% EYE DROPS LOWER COST ALTERNATIVES TIMOPTIC OPHTH SOLUTIONJADENU TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


JAKAFI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

JALYN 0.5-0.4 MG CAPSULE LOWER COST ALTERNATIVES FINASTERIDE PLUS TAMSULOSINJANUMET CLINICAL REVIEW REQUIRES CLINICAL REVIEWJANUMET XR CLINICAL REVIEW REQUIRES CLINICAL REVIEWJANUVIA CLINICAL REVIEW REQUIRES CLINICAL REVIEWJARDIANCE CLINICAL REVIEW REQUIRES CLINICAL REVIEWJENTADUETO CLINICAL REVIEW REQUIRES CLINICAL REVIEWJUBLIA SOL 10% CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWJUVISYNC 50-10 MG TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWJUVISYNC 50-20 MG TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWJUVISYNC 50-40 MG TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWJUXTAPID CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWKADIAN CLINICAL REVIEW REQUIRES CLINICAL REVIEW



KALYDECO CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

KAPVAY ER 0.1 MG TABLET LOWER COST ALTERNATIVES CLONIDINE (CATAPRES)KARBINAL ER SUSPENSION LOWER COST ALTERNATIVES CHLORPHENIRAMINE, DIPHENHYDRAMINEKAZANO 12.5-1,000 MG TABLET STEP THERAPY METFORMINKAZANO 12.5-500 MG TABLET STEP THERAPY METFORMINKEFLEX 750 MG CAPSULE LOWER COST ALTERNATIVES CEPHALEXIN 500 MGKENALOG AEROSOL SPRAY LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEKEPPRA XR TABLET LOWER COST ALTERNATIVES LEVETIRACETAM TABLETKEROL AD 45% EMULSION LOWER COST ALTERNATIVES UREA 40% CREAM , LOTIONKERYDIN TOPICAL SOLUTION LOWER COST ALTERNATIVE PENLAC, TERBINAFINEKEVEYIS TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWKEVZARA 150 MG, 200 MG INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWKHEDEZLA LOWER COST ALTERNATIVE 2 SSRIS, VENLAFAXINE ERKINERET 100 MG/0.67 ML SYR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


KIONEX 15 GM/60 ML SUSPENSI LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSKITABIS PAK CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


KOATE-DVI 500 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWKOGENATE FS 1,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWKOGENATE FS 2,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWKOGENATE FS 250 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWKOGENATE FS 3,000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWKOGENATE FS 500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWKORLYM CLINICAL REVIEW REQUIRES CLINICAL REVIEWKOVALTRY 3,000 UNIT KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWK-PHOS #2 TABLET LOWER COST ALTERNATIVES K-PHOS NEUTRAL TABLETK-PHOS M.F. TABLET LOWER COST ALTERNATIVES K-PHOS NEUTRAL TABLETKUVAN CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


KYNAMRO 200 MG/ML SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLACRISERT 5 MG EYE INSERT LOWER COST ALTERNATIVES ARTIFICIAL TEARSLAMICTAL ODT TABLET LOWER COST ALTERNATIVES LAMOTRIGINE TABLETLAMICTAL XR TABLET LOWER COST ALTERNATIVES LAMOTRIGINE TABLETLAMISIL GRANULES PAC LOWER COST ALTERNATIVES TERBINAFINE HCL 250 MG TABLLANSOPRAZOLE ODT TABLET LOWER COST ALTERNATIVES LANSOPRAZOLE DR CAPSULESLANTUS VIALS, SOLOSTAR PEN LOWER COST ALTERNATIVE BASAGLARLASTACAFT 0.25% EYE DROPS LOWER COST ALTERNATIVES KETOTIFENLATUDA ALL STRENGTHS LOWER COST ALTERNATIVES OLANZAPINE, RISPERIDONE, ZIPRASIDONE LATUDA TABLET LOWER COST ALTERNATIVES OLANZAPINE, RISPERIDONE, ZIPRASIDONELAZANDA SPRAY CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLENVIMA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLESCOL CAPSULE LOWER COST ALTERNATIVES SIMVASTATIN, ATORVASTATINLESCOL XL 80 MG TABLET LOWER COST ALTERNATIVES SIMVASTATIN, ATORVASTATINLETAIRIS TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,




LEUKINE VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

LEVATOL 20 MG TABLET LOWER COST ALTERNATIVES ATENOLOL, BISOPROLOL, METOPROLOLLEVEMIR LOWER COST ALTERNATIVE BASAGLARLEVODOPA/CARBIDOPA/ENTACAPONE

STEP THERAPY PRIOR USE OF CARBIDOPA/LEVODOPA

LEVORPHANOL 2 MG TABLET LOWER COST ALTERNATIVES MORPHINE SULFATE, OXYCODONELEXAPRO TABLET/ SOLUTION LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINELIALDA DR TABLET LOWER COST ALTERNATIVES ASACOL EC 400 MG TABLETLIDOCAINE 5% OINT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIDODERM 5% PATCH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIDOVIR 4%-4% LOWER COST ALTERNATIVES ACYCLOVIR OINTMENTLINDANE LOTION/ SHAMPOO STEP THERAPY FAILURE OF PERMETHRIN/RIDLINZESS 145 MCG CAPSULE LOWER COST ALTERNATIVES MIRALAX, LACTULOSELINZESS 290 MCG CAPSULE LOWER COST ALTERNATIVES MIRALAX, LACTULOSELIORESAL IT 0.05 MG/1 ML AM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIORESAL IT 10 MG/20 ML KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIORESAL IT 10 MG/5 ML KIT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIPOFEN CAPSULE LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGLIPTRUZET TABLET LOWER COST ALTERNATIVES ATORVASTATIN, SIMVASTATINLITHOSTAT 250 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLIVALO TABLET LOWER COST ALTERNATIVES SIMVASTATINLMX 4 PLUS KIT LOWER COST ALTERNATIVES LIDOCAINE OINT, LMX 4 4%CREAMLODOSYN 25 MG TABLET LOWER COST ALTERNATIVES SINEMET CRLOFIBRA LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGLO LOESTRIN FE LOWER COST ALTERNATIVE LOESTRIN, LOESTRIN FE, MIRCETTELO MINASTRIN FE TABLET CHEW LOWER COST ALTERNATIVES GENERIC ETHINYL ESTRADIOL/ NORETHINDRONELONSURF TABLET CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWLORZONE LOWER COST ALTERNATIVES CHLORZOXAZONE 500MG, TIZANIDINE, CARISPRODOLLOTEMAX LOWER COST ALTERNATIVE PREDNISOLONE ACETATE, DEXAMETHASONE,

FLUOROMETHOLONELOTRISONE LOWER COST ALTERNATIVES CLOTRIMAZOLE CRM SOLUTION LOTRONEX TABLET STEP THERAPY FAILURE OF METAMUCIL,PSYLLIUM, DICYCLOMINELOVAZA 1 GM CAPSULE LOWER COST ALTERNATIVES GENERIC FISH OIL. ONLY USED TO TREAT

TRIGLYCERIDES > 500LOVENOXPREFILLED SYR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLUMIGAN EYE DROPS LOWER COST ALTERNATIVES LATANAPROSTLUMINAL 130 MG/ML CARPUJECT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWLUNESTA TABLET LOWER COST ALTERNATIVES ZOLPIDEMLUXIQ 0.12% FOAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONELYNPARZA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


LYRICA CAPSULE LOWER COST ALTERNATIVES GABAPENTINMAGNACET MG TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENMAGNEBIND RX TABLET LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSMARNATAL-F CAPSULE LOWER COST ALTERNATIVES LACTOCAL-F TABLETMAVYRET LOWER COST ALTERNATIVES PA REQUIRED USE HARVONI/EPCLUSA GENERICS.


MAXAIR AUTOHALER 0.2 MG AER LOWER COST ALTERNATIVES PRO-AIR HFA



MAXALT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEMAXALT MLT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEMAXIDONE 10-750 MG TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENMAXIFED-G CD TABLET LOWER COST ALTERNATIVES GUAIFENESIN-CODEINE SYRUPMAXIFLU CD TABLET LOWER COST ALTERNATIVES PSEUDOEPHEDRINE, ACETOMINOPHEN TABLETSMEBARAL TABLET LOWER COST ALTERNATIVES PHENOBARBITALMEDROXYPROGESTERONE PREF SYR

LOWER COST ALTERNATIVES USE MEDROXYPROGESTERONE VIALS

MEFENAMIC ACID 250 MG CAPSU LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACMEGACE ES 625 MG/5 ML SUSP LOWER COST ALTERNATIVES MEGESTROL ACET 40 MG/ML SUSMEKINIST TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


M-END PE LIQUID LOWER COST ALTERNATIVES PROMETHAZINE VC-CODEINE SYRMENEST TABLET LOWER COST ALTERNATIVES ESTRADIOL TABLETSMENTAX 1% CREAM LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMMETANX TABLET LOWER COST ALTERNATIVES FOLIC ACIDMETAXALONE 800 MG TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLETS, CYCLOBENZAPRINE,

ORPHENADRINE, METHOCARBAMOLMETHADONE CLINICAL REVIEW REQUIRES CLINICAL REVIEWMETHITEST CLINICAL REVIEW REQUIRES CLINICAL REVIEWMETOZOLV ODT TABLET LOWER COST ALTERNATIVES METOCLOPRAMIDE, TABLETS, SOLUTIONMETOPROLOL 37.5 MG, 75 MG TABLET LOWER COST ALTERNATIVES METOPROLOL 25 MG, 50 MG, 100 MGMICARDIS HCT TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZ, IRBESARTAN-HCTZMICARDIS TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORMIGRANOW PACK LOWER COST ALTERNATIVES SUMATRIPTAN, NARATRIPTANMILLIPRED DP SOLUTION/ DOSE PACK

LOWER COST ALTERNATIVES PREDNISOLONE

MINASTRIN 24 FE CHEWABLE TA LOWER COST ALTERNATIVES GENERIC ORAL CONTRACEPTIVE WITH IRONMIRAPEX ER TABLET LOWER COST ALTERNATIVES PRAMIPEXOLE IMMEDIATE RELEASE TABLETMOLINDONE TABLET LOWER COST ALTERNATIVE RISPERIDONE, QUETIAPINE, ZIPRASIDONE,

OLANZAPINEMONOCLATE-P 1,000 UNITS KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWMONOCLATE-P 1,500 UNITS KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWMONONINE 1,000 UNITS VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWMONUROL 3 GM SACHET LOWER COST ALTERNATIVES CEPHALOSPORIN, CIPROFLOXACINMOTOFEN TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWMOVANTIK CAPSULE LOWER COST ALTERNATIVE MIRALAX, LACTULOSEMOVIPREP POWDER KIT LOWER COST ALTERNATIVES COLYTE, GOLYTELY, NULYTELYMOXATAG ER 775 MG TABLET LOWER COST ALTERNATIVES AMOXICILLIN 500 MG TABLETMOXEZA 0.5% EYE DROPS LOWER COST ALTERNATIVES CIPROFLOXACIN 0.3% EYE DROPMUCINEX COLD & SINUS LOWER COST ALTERNATIVES GUAIFENESIN SYRUPMUCINEX COLD-FLU & SORE THROAT

LOWER COST ALTERNATIVES GUAIFENESIN/DEXTROMETHORPHAN/PHENYLEPHRINE

MYCOLOG II LOWER COST ALTERNATIVES NYSTATIN CRM OINTMYRBETRIQ LOWER COST ALTERNATIVE OXYBUTYNIN/ER, TROSPIUMMYTELASE 10 MG CAPLET LOWER COST ALTERNATIVES NEOSTIGMINE, PYRIDOSTIGMINENAFTIN LOWER COST ALTERNATIVES CLOTRIMAZOLE, KETOCONAZOLE TOPICALNAFTIN 1% CREAM/GEL LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMNAFTIN 2% GEL LOWER COST ALTERNATIVES CLOTRIMAZOLE CRM SOLUTION, MICONAZOLE CRMNALFON 200 MG PULVULE LOWER COST ALTERNATIVES FENOPROFEN, OTHER GENERIC NSAIDS, NALFON CAPSULE LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLAC



NAMENDA XR LOWER COST ALTERNATIVE MEMANTINE IRNAMZARIC ER LOWER COST ALTERNATIVE MEMANTINE, DONEPEZILNAPRELAN CR LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACNASACORT AQ NASAL SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONENASCOBAL 500 MCG NASAL SPRAY LOWER COST ALTERNATIVES CYANOCOBALAMIN 1,000 MCG/MLNASONEX 50 MCG NASAL SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONENATACYN EYE DROPS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNATELLE ONE CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNATESTO NASAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNATPARA POWDER FOR INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,

MEDICATION MUST BE OBTAINED FROM SPECIALTYPHARMACY

NECON 10/11 LOWER COST ALTERNATIVE MIRCETTENEEVO DHA GELCAP LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNEOBENZ MICRO CREAM/ WASH PLUS PAC

LOWER COST ALTERNATIVES BENZOYL PEROXIDE 5% OR 10% LOTION

NEO-SYNALAR CREAM LOWER COST ALTERNATIVE USE TRIAMCINOLONE, BETAMETHASONE,FLUOCINOLONE

NEPHPLEX RX TABLET LOWER COST ALTERNATIVES FOLIC ACIDNEPHROCAPS QT TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEPHRON FA TABLET LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLNESINA 12.5 MG TABLET STEP THERAPY METFORMINNESINA 25 MG TABLET STEP THERAPY METFORMINNESINA 6.25 MG TABLET STEP THERAPY METFORMINNESTABS ABC PRENATAL COMBO LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONNEUAC KIT LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONNEULASTA 6 MG/0.6 ML SYRING CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEUMEGA 5 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEUPOGEN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEVANAC 0.1% DROPTAINER LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONNEXA SELECT CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNEXA SELECT SOFTGEL LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONNEXAVAR 200 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNEXICLON XR 0.09 MG/ML SUSP LOWER COST ALTERNATIVES CLONIDINE TABLETSNEXICLON XR 0.17 MG TABLET LOWER COST ALTERNATIVES CLONIDINE TABLETSNEXIUM LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE,

NEXIUM OTCNIASPAN ER TABLET LOWER COST ALTERNATIVES GENERIC ER NIACINNICOTROL CARTRIDGE INHALER STEP THERAPY NICOTINE PATCH/GUM, BUPROPRION SRNICOTROL NS 10 MG/ML SPRAY STEP THERAPY NICOTINE PATCH/GUM, BUPROPRION SRNINLARO CAPSULE CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW,


NOROXIN 400 MG TABLET LOWER COST ALTERNATIVES CIPROFLOXACINNORTHERA CAP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNOVOLOG CARTRIDGE CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOLOG P/F PEN CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOLOG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOSEVEN 1,200 MCG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOSEVEN 2,400 MCG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOSEVEN RT 1,000 MCG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOSEVEN RT 2,000 MCG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEW



NOVOSEVEN RT 5,000 MCG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOVOSEVEN RT 8,000 MCG VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWNOXAFIL 40 MG/ML SUSPENSION LOWER COST ALTERNATIVES FLUCONAZOLE, ITRACONAZOLE,NOXAFIL DR 100 MG TABLET LOWER COST ALTERNATIVES ITRACONAZOLE, VORICONAZOLENUCYNTA ER LOWER COST ALTERNATIVES TRAMADOL ERNUCYNTA TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETNUEDEXTA 20-10 MG CAPSULE CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIANUPLAZID TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWNUOX GEL LOWER COST ALTERNATIVES BENZOYL PEROXIDE 5% OR 10% LOTIONNUVESSA VAGINAL GEL LOWER COST ALTERNATIVE METRONIDAZOLE GELNUVIGIL 50 MG TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUVIGIL 150 MG TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUVIGIL 250 MG TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ INJ 250 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ INJ 500 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ INJ 1000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ INJ 2000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEW

NUWIQ KIT 250 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ KIT 500 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ KIT 1000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNUWIQ KIT 2000 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWNYDAMAX 0.75% GEL LOWER COST ALTERNATIVES METROLOTION TOPICAL 0.75%,NYMALIZE 60 MG/20 ML SOLUTI LOWER COST ALTERNATIVES NIMODIPINE TABLETSOB COMPLETE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONOB COMPLETE PETITE SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMINSOBIZUR 500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWOCALIVA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWODOMZO CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW,


OFEV CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOLEPTRO ER 150 MG TABLET LOWER COST ALTERNATIVES TRAZODONEOLEPTRO ER 300 MG TABLET LOWER COST ALTERNATIVES TRAZODONEOLYSIO 150 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


OMECLAMOX-PAK COMBO PACK 20(20)-500

LOWER COST ALTERNATIVES PREV-PAK

OMEPRAZOLE-BICARB 40-1,100 LOWER COST ALTERNATIVES OMEPRAZOLE; PLUS SODIUM BICARB.OMNARIS 50 MCG NASAL SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONEONEXTON 1.2%-3.75% GEL LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONONEXTON GEL PUMP LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONONFI TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWONGLYZA CLINICAL REVIEW REQUIRES CLINICAL REVIEWONMEL 200 MG TABLET LOWER COST ALTERNATIVES ITRACONAZOLE 100 MG TABLETSONSOLIS SOLUBLE FILM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWONZETRA NASAL SPRAY LOWER COST ALTERNATIVES SUMATRIPTAN, NARATRIPTANOPANA TABLET LOWER COST ALTERNATIVES OXYMORPHONE TABLETSOPANA ER TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOPIUM TINCTURE 10 MG/ML LOWER COST ALTERNATIVES IMODIUM, DICYCLOMINE



OPSUMIT 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

ORACEA 40 MG CAPSULE LOWER COST ALTERNATIVES DOXYCYCLINE 50 MG CAPSULEORALAIR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ORAPRED ODT TABLET LOWER COST ALTERNATIVES PREDNISOLONEORAVIG 50 MG BUCCAL TABLET LOWER COST ALTERNATIVES NYSTATIN 100,000 UNITS/ML SORENCIA INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWORENCIA SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ORFADIN CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWORFADIN SUSPENSION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWORKAMBI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ORPHENADRINE COMP FORTE TAB LOWER COST ALTERNATIVES TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL

ORPHENADRINE COMP TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLETS, CYCLOBENZAPRINE, ORPHENADRINE, METHOCARBAMOL

OSENI 12.5-15 MG TABLET STEP THERAPY METFORMINOSENI 12.5-30 MG TABLET STEP THERAPY METFORMINOSENI 12.5-45 MG TABLET STEP THERAPY METFORMINOSENI 25-15 MG TABLET STEP THERAPY METFORMINOSENI 25-30 MG TABLET STEP THERAPY METFORMINOSENI 25-45 MG TABLET STEP THERAPY METFORMINOTEZLA 10 MG, 20 MG, 30 MG CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOTOVEL DROPS LOWER COST ALTERNATIVES CIPROFLOXACINOTREXUP AUTO-INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


OVACE PLUS 10% WASH LOWER COST ALTERNATIVES SODIUM SULFACETAMIDE WASH 10%OVACE PLUS LOT 9.8% LOWER COST ALTERNATIVE USE SODIUM SULFACETAMIDE WASH 10%OVCON CLINICAL REVIEW REQUIRES CLINICAL REVIEWOXANDROLONE 10 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXANDROLONE 2.5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXECTA LOWER COST ALTERNATIVES OXYCODONE GENERIC TABLETOXISTAT 1% CREAM/LOTION LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMOXSORALEN 1% LOTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXYTROL FOR WOMEN 3.9 MG/24 LOWER COST ALTERNATIVES OXYBUTYNIN/ER, TROSPIUM TABLETSOXYCODONE-IBUPROFEN 5-400 T LOWER COST ALTERNATIVES HYDROCODONE WITH IBUPROFEN TABLETSOXYCONTIN TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWOXYMORPHONE HCL ER TAB CLINICAL REVIEW REQUIRES CLINICAL REVIEWOXYTROL 3.9 MG/24HR PATCH LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20 MGOZEMPIC 0.25 MG, 0.5 MG, 1 MG INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPACNEX HP 7% CLEANSING PADS LOWER COST ALTERNATIVES BENZOYL PEROXIDE SOLUTIONPACNEX LP 4.25% CLEANSING P LOWER COST ALTERNATIVES BENZOYL PEROXIDE SOLUTIONPACNEX MX 4.25% CLEANSER LOWER COST ALTERNATIVES BENZOYL PEROXIDE SOLUTIONPACNEX WASH/PADS LOWER COST ALTERNATIVES BENZOYL PEROXIDE 5% OR 10% LOTIONPAIRE OB PLUS DHA COMBO PAC LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPALGIC 4 MG TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINE



PANDEL 0.1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEPANRETIN 0.1% GEL LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEPARCOPA ODT LOWER COST ALTERNATIVES CARBIDOPA-LEVO 25-250 MG ODTPAROXETINE CR TABLET LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINEPATADAY 0.2% DROPS LOWER COST ALTERNATIVE KETOTIFENPATANASE 0.6% NASAL SPRAY LOWER COST ALTERNATIVES ASTEPRO 0.15% NASAL SPRAYPATANOL 0.1% EYE DROPS LOWER COST ALTERNATIVES KETOTIFENPAZEO EYE DROPS LOWER COST ALTERNATIVE KETOTIFENPEDIADERM AF KIT LOWER COST ALTERNATIVES NYSTATIN CREAM, OINTMENTPEDIADERM TOPICAL LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONEPEDIPIROX-4 LOWER COST ALTERNATIVES CICLOPIROX 8%/VITAMIN E KITPEGASYS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PEGINTRON INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PENNSAID 1.5% SOLUTION LOWER COST ALTERNATIVES USE VOLTAREN GELPENTAM 300 VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPENTASA LOWER COST ALTERNATIVE APRISO, ASACOL HDPENTAZOCIN-ACETAMINOPHN LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENPERFOROMIST LOWER COST ALTERNATIVES SEREVENTPERTZYE LOWER COST ALTERNATIVE CREON, ZENPEP, PANCREAZEPEXEVA TABLET LOWER COST ALTERNATIVES CITALOPRAM, FLUOXETINE, SERTRALINEPHOSLYRA SOLUTION LOWER COST ALTERNATIVES CALCIUM ACETATE 667MG TABLETPICATO LOWER COST ALTERNATIVES REQUEST MUST GO THROUGH CLINICAL REVIEWPLEGRIDY CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PLEXION CLEANSING CLOTHS LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE, CLINDAMYCIN SOLUTION

PNV-DHA PLUS SOFTGEL LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPNV FOLIC ACID + IRON TABLET LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONPNV-IRON TABLET LOWER COST ALTERNATIVES LACTOCAL-F TABLETPOLY IRON PN FORTE TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPOMALYST 1 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOLY-VI-FLOR LOWER COST ALTERNATIVE USE GENERIC MULTIVITAMIN WITH FLUORIDEPOMALYST 2 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOMALYST 3 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOMALYST 4 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPOTASSIUM CL 25 MEQ TAB EFF LOWER COST ALTERNATIVES KLOR-CON 25 MEQ PACKETPOTIGA ALL STRENGTHS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPRADAXA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPRALUENT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PRANDIMET TABLET LOWER COST ALTERNATIVES SULPHONYLUREA PLUS METFORMINPRASCION RA CREAM LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONPREFERA-OB PLUS DHA COMBO P

LOWER COST ALTERNATIVES USE GENERIC PRENATAL VITAMIN WITH DHA



PREGNYL 10,000 UNITS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PREMARIN TABLETS LOWER COST ALTERNATIVES ESTRADIOL TABLETSPREMPHASE LOWER COST ALTERNATIVES USE FORMULARY ALTERNATIVE ESTROGEN/

PROGESTIN PRODUCTSPREMPRO LOWER COST ALTERNATIVES USE FORMULARY ALTERNATIVE ESTROGEN/

PROGESTIN PRODUCTSPRENACARE TABLET LOWER COST ALTERNATIVES COMPLETE-RF PRENATAL TABLETPRENAISSANCE NEXT LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH MINERALSPRENAISSANCE NEXT-B TABLET LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERICPRENATE AM TABLET LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONPRENATE DHA SOFTGEL LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLETPRENATE ESSENTIAL SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMINPRENATE MINI SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMINPRENATE PIXIE LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLETPRENATE SOFTGEL LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERICPRENATE SOFTGEL/ TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPRENATE STAR TABLET LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLETPRENEXA CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPREQUE 10 TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONPRIFTIN 150 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPRIMLEV TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENPRIMSOL 50 MG/5 ML ORAL SOL LOWER COST ALTERNATIVES CEPHALOSPORIN, CIPROFLOXACINPRISTIQ TABLET LOWER COST ALTERNATIVES VENLAFAXINE ER CAPSULESPRIVIGEN 10% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PROAIR RESPICLICK INHAL POW LOWER COST ALTERNATIVES ALBUTEROL 90 MCG INHALERPROBARIMIN QT TABLET LOWER COST ALTERNATIVES MULTIVITAMIN GENERICPROCENTRA 5 MG/5 ML SOLUTIO LOWER COST ALTERNATIVES AMPHETAMINE, DEXTROAMPHETAMINE,

ADDERALL XRPROCRIT 10,000 UNITS/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


PROCRIT 2,000 UNITS/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PROCRIT 20,000 UNITS/ML VIA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



PROCRIT 40,000 UNITS/ML VIA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PROFILNINE SD 500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWPROFILNINE SD 1, 000 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWPROFILNINE SD 1,500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWPROLENSA 0.07% EYE DROPS LOWER COST ALTERNATIVES BROMFENAC OPHTH, KETOROLAC OPHTH



PROLEUKIN 22 MILLION UNIT V CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

PROLIA 60 MG/ML INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPROMACTA 12.5 MG CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPROMACTA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPROPARACAINE 0.5% EYE DROPS LOWER COST ALTERNATIVES TETRACAINE OPHTH SOLUTIONPROQUIN XR 500 MG TABLET LOWER COST ALTERNATIVES CIPROFLOXACINPRO-RED AC SYRUP LOWER COST ALTERNATIVES CODEINE, ANTIHISTAMINE, PHENYLEPHRINE

COMBINATIONPROSED-DS TABLET LOWER COST ALTERNATIVES URELLE TABLETPROTONIX 40 MG SUSPENSION LOWER COST ALTERNATIVES OMEPRAZOLE, LANSOPRAZOLE, PANTOPRAZOLE.PROTOPIC OINTMENT LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEPROVENTIL HFA 90 MCG INHALE LOWER COST ALTERNATIVES ALBUTEROL 90 MCG INHALERPROVIDA DHA CAPSULE LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH DHAPROVIDA OB CAPSULE LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMIN WITH IRONPROVIGIL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPULMICORT FLEXHALER LOWER COST ALTERNATIVE QVAR, AEROSPAN, ARNUITY ELLIPTAPULMOZYME AMPUL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWPV VITAMIN D 400 UNIT TABLET LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERIC PYLERA CAPSULE LOWER COST ALTERNATIVES PREVPAC PATIENT PACKQBRELIS SOLUTION LOWER COST ALTERNATIVES LISINOPRILQNASL 80 MCG LOWER COST ALTERNATIVES FLUTICASONE, FLUNISOLIDE NASAL SPRAYQUDEXY XR CAP LOWER COST ALTERNATIVE USE TOPIRAMATEQUFLORA PEDIATRIC LOWER COST ALTERNATIVE USE MULTIVITAMINS/FLUORIDE DROPSQUARTETTE TABLET LOWER COST ALTERNATIVES EE/LEVONORGESTREL GENERICQUILLIVANT XR 25 MG/5 ML SU LOWER COST ALTERNATIVES GENERIC METHYLPHENIDATE WITH SPRINKLE

CAPABILITY (METADATE CD)QUIXIN 0.5% EYE DROPS LOWER COST ALTERNATIVES LEVOFLOXACIN OPHTHRAGWITEK SUB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWRAPAFLO CAPSULE LOWER COST ALTERNATIVES TAMSULOSIN, TERAZOSIN AND DOXAZOSINRASUVO INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWRAYALDEE CLINICAL REVIEW REQUIRES CLINICAL REVIEWREBETOL 40 MG/ML SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


REBIF REBIDOSE 22 MCG/0.5 M CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REBIF REBIDOSE 44 MCG/0.5 M CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REBIF REBIDOSE TITRATION PA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

REBIF SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RECOMBINATE 220-400 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWRECOMBINATE 401-800 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWRECOMBINATE 801-1,240 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWRECOMBINATE 1,241-1,800 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWRECOMBINATE 1,801-2,400 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWRECTIV LOWER COST ALTERNATIVES ANUSOL HC OINTMENT



REGRANEX 0.01% GEL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWRELPAX TABLET LOWER COST ALTERNATIVES IMITREX, AMERGERELISTOR TABLET LOWER COST ALTERNATIVES MIRALAX, LACTULOSEREMICADE 100 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


REMODULIN INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RENAGEL TABLET LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSRENVELA POWDER/TABLET LOWER COST ALTERNATIVES CALCIUM ACETATE 667 MG CAPSREPATHA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


REPREXAIN TABLET LOWER COST ALTERNATIVES HYDROCODONE WITH IBUPROFEN TABLETSREQUIP XL TABLET LOWER COST ALTERNATIVES REQUIP IMMEDIATE RELEASE TABLETRESCULA 0.15% EYE DROPS LOWER COST ALTERNATIVES LATANOPROST OPHTH SOLUTIONRETIN-A MICR GEL 0.08% LOWER COST ALTERNATIVE DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONREVATIO INJECTION AND TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


REVATIO SUS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWREVLIMID 20 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


REVLIMID CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWREXULTI TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWRHINARIS NASAL GEL LOWER COST ALTERNATIVES SODIUM CHLORIDE NASAL SOLUTIONRHINOCORT AQUA NASAL SPRAY LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONERHOPHYLAC 300 MCG/2 ML SYR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


RIBAPAK CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIBASPHERE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIBAVIRIN CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

RIFAMATE CAPSULE LOWER COST ALTERNATIVES RIFAMPIN 300 MG PLUS ISONIAZIDRIFATER LOWER COST ALTERNATIVE ISONIAZID + PYRAZINAMIDE + RIFAMPINRILUTEK 50 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


RITALIN LA 60MG LOWER COST ALTERNATIVE METADATE CD, CONCERTARITALIN LA 10MG LOWER COST ALTERNATIVE METADATE CD, CONCERTARITUXAN 10 MG/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


RIXUBIS 250 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWRIXUBIS 500 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWRIXUBIS 1,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWRIXUBIS 2,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEW



RIXUBIS 3,000 UNIT NOMINAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWROSULA WASH LOWER COST ALTERNATIVE SULFACETAMIDE/SULFUR CREAM, GEL, LOTION, PADSROVIN-A DHA LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH MINERALSROVIN-NV DHA CAPSULE LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONROZEREM TABLET LOWER COST ALTERNATIVES ZOLPIDEMRUBRACA CLINICAL REVIEW REQUIRES CLINICAL REVIEWRYBIX ODT 50 MG TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETRYNATAN PEDIATRIC CHEWABLE LOWER COST ALTERNATIVES RYNATAN PEDIATRIC ORAL SUSPRYTARY ER LOWER COST ALTERNATIVE CARBIDOPA/LEVODOPA RYZOLT LOWER COST ALTERNATIVE TRAMADOLRYZOLT ER TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETSABRIL 500 MG TABLET\ POWDER CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIASAIZEN 5 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SAIZEN 8.8 MG CLICK.EASY CA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SAIZEN 8.8 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SALKERA 6% FOAM LOWER COST ALTERNATIVES SALICYLIC ACID 6% LOTION KISAMSCA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSANCTURA 20 MG TABLET STEP THERAPY FAILURE OXYBUTYNIN/ERSANCTURA XR 60 MG CAPSULE LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20 MGSANCUSO 3.1 MG/24 HR PATCH LOWER COST ALTERNATIVES ONDANSETRONSANTYL CLINICAL REVIEW REQUIRES CLINICAL REVIEWSAPHRIS TABLET SUBLING LOWER COST ALTERNATIVES RISPERIDONE, GEODON, ZYPREXA, SEROQUELSAVAYSA TABLET CLINICAL REVIEW REQUST MUST GO THROUGH CLINICAL REVIEWSAVELLA TABLET LOWER COST ALTERNATIVES GABAPENTINSCOPACE 0.4 MG TABLET LOWER COST ALTERNATIVES MECLIZINE TABLETSEASONIQUE CLINICAL REVIEW REQUIRES CLINICAL REVIEWSE-CARE TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONSECONAL CAPSULE LOWER COST ALTERNATIVE ZOLPIDEMSEGLUROMET STEP THERAPY PREQUISITES INCLUDE DPP-4 INHIBITORS, SGLT2

INHIBITORS, DPP-4 INHIBITOR-BIGUANIDE COMBINATIONS

SELECT-OB CHEWABLE CAPLET LOWER COST ALTERNATIVE USE PRENAISSANCE NEXT PRENATAL TABLETSENSIPAR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSERNIVO SPRAY LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONESEROMYCIN 250 MG CAPSULE LOWER COST ALTERNATIVES RIFAMPIN 300 MG PLUS ISONIAZIDSEROQUEL XR LOWER COST ALTERNATIVES GENERIC QUETIAPINE IRSEROSTIM INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SE-TAN CAPSULE LOWER COST ALTERNATIVES FERROUS SULFATE 325 MG TABLSIGNIFOR 0.3 MG/ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSIGNIFOR 0.6 MG/ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSIGNIFOR 0.9 MG/ML AMPULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSILENOR TABLET LOWER COST ALTERNATIVES DOXEPINSIMBRINZA 1%-0.2% EYE DROPS LOWER COST ALTERNATIVES DORZOLAMIDE/TIMOLOL OPHTH



SIMCOR TABLET LOWER COST ALTERNATIVES NIACIN PLUS SIMVASTATINSIMPONI 50 MG/ML SYRINGE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SIMPONI INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

SINGULAIR TAB/GRAN/CHEW STEP THERAPY FAILURE OF INHALED STEROIDSINUS RELIEF CONGESTION & PAIN LOWER COST ALTERNATIVES OTC DECONGESTANT/ACETOMINOPHENSIRTURO 100 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSITAVIG TAB LOWER COST ALTERNATIVE USE ABREVA, ORAL ACYCLOVIRSIVEXTRO TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW SKELID 200 MG TABLET LOWER COST ALTERNATIVES GENRIC ALENDRONATESOLARAZE 3% GEL CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIASOLODYN ER TABLET LOWER COST ALTERNATIVES MINOCYCLINE 75MG, 100 MG CAPSULESOMA 250 MG TABLET LOWER COST ALTERNATIVES TIZANIDINE TABLET; CARISOPRODOL TABLETSOMAVERT INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSORIATANE CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSORILUX 0.005% FOAM LOWER COST ALTERNATIVES DOVONEX OINT, CREAMSOTYLIZE SOLUTION LOWER COST ALTERNATIVE SOTALOL TABLETSSOLVALDI LOWER COST ALTERNATIVES PA REQUIRED USE HARVONI/EPCLUSA GENERICSSOVALDI 400 MG TABLET LOWER COST ALTERNATIVES PA REQUIRED USE HARVONI/EPCLUSA GENERICSSPECTRACEF DOSE PACK LOWER COST ALTERNATIVES CEFPODOXIME PROXETILSPIRIVA HANDIHALER LOWER COST ALTERNATIVES INCRUSE ELLIPTASPIRIVA RESPIMAT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSPORANOX 10 MG/ML SOLUTION LOWER COST ALTERNATIVES REQUEST MUST GO THROUGH CLINICAL REVIEWSPRITAM TABLETS LOWER COST ALTERNATIVES LEVETIRACETAM/XRSPRYCEL TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


STAVZOR DR CAPSULE LOWER COST ALTERNATIVES DEPAKOTE ER 500 MG TABLETSTEGLATRO STEP THERAPY PREQUISITES INCLUDE DPP-4 INHIBITORS, SGLT2

INHIBITORS, DPP-4 INHIBITOR-BIGUANIDE COMBINATIONS

STIOLTO RESPIMAT LOWER COST ALTERNATIVES ANORO ELLIPTASTIMATE 1.5 MG/ML NASAL SPR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSTIVARGA 40 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


STRATTERA CAPSULE STEP THERAPY FAILURE OF METHYLPHENIDATE, AMPHETAMINE PRODUCT

STRIANT 30 MG MUCOADHESIVE CLINICAL/STEP REQUEST MUST GO THROUGH CLINICAL REVIEW, REQUIRES LAB VALUES

STRIBILD TABLETS ALL STRENGTHS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSTRIVERDI AER RESPIMAT LOWER COST ALTERNATIVE USE SERVENTSUBLOCADE 100/0.5 ML ER INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSUBLOCADE 300/0.5 ML ER INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSUBSYS CLINICAL REVIEW REQUIRES CLINICAL REVIEWSUCRAID 8,500 UNITS/ML SOLN CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSULFAMYLON POWDER PACKET LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONSUMADAN LOWER COST ALTERNATIVES SULFACETAMIDE SOLUTIONSUMADAN LOWER COST ALTERNATIVES SULFACETAMIDE TOPICAL LOTION



SUMADAN LOTION LOWER COST ALTERNATIVES SULFACETAMIDE SODIUM LOTIONSUMAVEL DOSEPRO 6 MG/0.5 ML LOWER COST ALTERNATIVES SUMATRIPTAN INJECTION, TABLETSSUMAXIN CP LOWER COST ALTERNATIVES SULFACETAMIDE TOPICAL LOTIONSUMAXIN PADS/WASH LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONSUMAXIN TS TOPICAL SUSPENSI LOWER COST ALTERNATIVES SULFACETAMIDE SOLUTIONSUPRAX SUSPENSION LOWER COST ALTERNATIVES CEFPODOXIME PROXETILSUPRAX 100 MG TABLET CHEWABLE

LOWER COST ALTERNATIVES GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME)

SUPRAX 200 MG TABLET CHEWABLE

LOWER COST ALTERNATIVES GENERIC 3RD GENERATION SUSPENSION (CEFPODOXIME)

SUPRAX 400 MG TABLET LOWER COST ALTERNATIVES CEFPODOXIME PROXETILSUPRAX CAPSULE, SUSPENSION LOWER COST ALTERNATIVES CEFPODOXIME SUSPENSION/CAPSULESSUPREP BOWEL PREP KIT LOWER COST ALTERNATIVES COLYTE, GOLYTELY, NULYTELYSUTENT CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYLATRON CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SYLVANT SOL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYMBICORT STEP THERAPY FOR AGES 6-12, PREREQUISITES INCLUDE ICS OR ICS/

LABA, ALL OTHER AGES, PREREQUISITES INCLUDE INHALED LABA OR ANTIMUSCARINIC AGENTS

SYMBYAX CAPSULE LOWER COST ALTERNATIVES ZYPREXA PLUS FLUOXETINESYMLIN 0.6 MG/ML VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYMLINPEN PEN/VIAL STEP THERAPY FAILURE OF INSULIN THERAPYSYNAGIS INJECTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


SYNALGOS-DC CAPSULE LOWER COST ALTERNATIVES CODEINE WITH ACETOMINOPHEN,SYNAREL 2 MG/ML NASAL SPRAY CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYNERCID 500 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYNJARDY TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWSYPRINE 250 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWTAFINLAR CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TAGRISSO TABLET CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TANZEUM INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWTARCEVA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TARON EC CALCIUM DHA COMB P LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTARON-DUO EC COMB PACK LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTARON-EC CAL TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTARON-PREX PRENATAL DHA CAP LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTASIGNA CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TECFIDERA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY



TECHNIVIE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TEKTURNA HCT TABLET STEP THERAPY FAILURE ACE/ARBTEKTURNA TABLET STEP THERAPY FAILURE ACE/ARBTEMODAR CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TESTIM CLINICAL REVIEW REQUIRES CLINICAL REVIEWTESTRED CLINICAL REVIEW REQUIRES CLINICAL REVIEW

TEVETEN TABLET LOWER COST ALTERNATIVES LOSARTAN OR ACE-INHIBITORTEV-TROPIN 5 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


THALOMID CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

THEROBEC TABLET LOWER COST ALTERNATIVES FOLBEE PLUSTHRIVITE 19 TABLET LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMINTINDAMAX TABLET LOWER COST ALTERNATIVES METRONIDAZOLE 250 MG TABLETTIROSINT CAPSULE LOWER COST ALTERNATIVES GENERIC LEVOTHYROXINETL-ASSURE + DHA LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH MINERALSTL-SELECT DHA SOFTGEL LOWER COST ALTERNATIVES GENERIC PRENATAL VITAMINSTOBI PODHALER 28 MG INHALE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TOBI PODHALER INHALER CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TOLMETIN SODIUM 600 MG TAB LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACTOPICORT 0.25% SPRAY LOWER COST ALTERNATIVES BETAMETHASONE CRM/LOT, DESOXIMETASONE CRMTOPICORT GEL LOWER COST ALTERNATIVE USE BETAMETHASONETOPIRAMATE CAP ER LOWER COST ALTERNATIVE USE TOPIRAMATETOUJEO SOLOSTAR LOWER COST ALTERNATIVE BASAGLARTOVIAZ ER TABLET LOWER COST ALTERNATIVES OXYBUTYNIN/XL, TROSPIUM 20MGTRACLEER TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TRADJENTA TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWTRAVATAN Z 0.004% EYE DROP LOWER COST ALTERNATIVES LATANAPROSTTRAVOPROST 0.004% EYE DROP LOWER COST ALTERNATIVES LATANOPROST OPHTH SOLTRAZODONE 300 MG LOWER COST ALTERNATIVES TRAZODONE 50 MG, TRAZODONE 100 MG,

TRAZODONE 150 MGTRESIBA FLEXTOUCH CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWTRETINOIN CREAM 0.025% STEP THERAPY DIFFERIN GEL 0.1% OTCTRETINOIN CREAM 0.05% STEP THERAPY DIFFERIN GEL 0.1% OTCTRETINOIN CREAM 0.1% STEP THERAPY DIFFERIN GEL 0.1% OTCTRETINOIN GEL 0.01% STEP THERAPY DIFFERIN GEL 0.1% OTCTRETINOIN GEL 0.025% STEP THERAPY DIFFERIN GEL 0.1% OTCTRETTEN 2,500 UNIT VIAL CLINICAL REVIEW REQUIRES CLINICAL REVIEWTREXIMET LOWER COST ALTERNATIVES SUMATRIPTAN AND NAPROXEN TABLETSTRIANEX OINTMENT LOWER COST ALTERNATIVE TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONETRIAZ PAD/FOAM LOWER COST ALTERNATIVES TRIAZ CLEANSERTRIBENZOR TABLET LOWER COST ALTERNATIVES LOSARTAN-HCTZ PLUS AMLODIPINE



TRICARE PRENATAL COMPLEAT P

LOWER COST ALTERNATIVES PRENATAL VITAMIN GENERIC IN WITH IRON

TRICARE PRENATAL TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTRICOR TABLET LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGTRIGLIDE TABLET LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGTRILIPIX DR CAPSULE LOWER COST ALTERNATIVES GENERIC FENOFIBRATE 54 MG OR 160 MGTRI-LUMA CREAM LOWER COST ALTERNATIVES RETIN A CREAM/GELTRIMESIS RX TABLET LOWER COST ALTERNATIVES PRENATAL VITAMINS WITH IRONTRINTELLIX LOWER COST ALTERNATIVE 2 SSRIS, VENLAFAXINE ERTRISTART DHA SOFTGEL LOWER COST ALTERNATIVE USE GENERIC PRENATAL VITAMIN WITH DHATRI-TABS DHA COMBO PACK LOWER COST ALTERNATIVES PRENATAL VITAMIN WITH IRONTRIUMEQ TAB LOWER COST ALTERNATIVE USE EPZICOM WITH TIVICAYTROKENDI XR CAPSULE LOWER COST ALTERNATIVES TOPIRAMATETRULICITY INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWTUDORZA LOWER COST ALTERNATIVE INCRUSE ELLIPTATUSSIONEX PENNKINETIC SUSP LOWER COST ALTERNATIVES HYDROCODONE-HOMATROPINE SYRTWINJECT AUTO-INJECT LOWER COST ALTERNATIVES EPI PEN, EPI PEN JRTWYNSTA TABLET LOWER COST ALTERNATIVES LOSARTAN PLUS AMLODIPINETYGACIL 50 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TYKERB TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

TYMLOS 80 MCG/DOSE INJ CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWTYVASO INHALATION SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


TYZINE NOSE DROPS/ SPRAY LOWER COST ALTERNATIVES NOSE DROPS 1%, AFRIN NASAL SPRAYTYZINE PEDIATRIC 0.05% DROP LOWER COST ALTERNATIVES OXYMETOLAZINE NASAL SPRAYUCERIS RECTAL FOAM CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWULESFIA LOWER COST ALTERNATIVE RID, NIXULESFIA 5% LOTION STEP THERAPY FAILURE OF PERMETHRIN AND RID AND MALATHIONULORIC TABLET LOWER COST ALTERNATIVES ALLOPURINOL TABLETULTRACET TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLET AND ACETAMINOPHEN TABULTRAM ER TABLET LOWER COST ALTERNATIVES TRAMADOL HCL TABLETULTRAVATE LOTION LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE, FLUOCINOLONEULTRESA DR 20,700 UNIT CAPS LOWER COST ALTERNATIVES CREON, ZENPEP, PANCREAZEULTRESA DR 23,000 UNIT CAPS LOWER COST ALTERNATIVES CREON, ZENPEP, PANCREAZEUPTRAVI CLINICAL REVIEW REQUIRES CLINICAL REVIEWUREA LOTION/GEL LOWER COST ALTERNATIVES UREA 40% CREAM , LOTIONUROQID-ACID NO.2 500-500 TB LOWER COST ALTERNATIVES K-PHOS NEUTRAL TABLETUROXATRAL 10 MG TABLET LOWER COST ALTERNATIVES TAMSULOSIN, TERAZOSIN AND DOXAZOSIN.UTIBRON NEOHALER CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWVAGIFEM 10 MCG VAGINAL TAB LOWER COST ALTERNATIVES USE ESTRACE CREAMVALCHLOR 0.016% GEL LOWER COST ALTERNATIVES HP STEROID CREAMVALCYTE CLINICAL REVIEW REQUIRES CLINICAL REVIEWVALTURNA TABLET STEP THERAPY FAILURE ACE/ARBVANATOL LQ ORAL SOLUTION LOWER COST ALTERNATIVE BUTALBITAL/APAP/CAFFEINE 50/325/40 TABLETSVANCOMYCIN CAPSULES LOWER COST ALTERNATIVE FIRST-VANCOMYCIN COMPOUND KITVANOS 0.1% CREAM LOWER COST ALTERNATIVES TRIAMCINOLONE, BETAMETHASONE,

FLUOCINOLONE



VARUBI TABLET LOWER COST ALTERNATIVE ONDANSETRONVASCEPA 0.5 GM CAPSULE; ONLY USED TO TREAT TRIGLYCERIDES > 500

LOWER COST ALTERNATIVE GENERIC FISH OIL

VASCEPA 1 GM CAPSULE LOWER COST ALTERNATIVES GENERIC FISH OIL; ONLY USED TO TREAT TRIGLYCERIDES > 500

VECAMYL TABLET LOWER COST ALTERNATIVES METHYLPHENIDATE, CLONIDINE, PERGOLIDE VELETRI INFUSION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VELTASSA POWDER PACK CLINICAL REQUEST MUST GO THROUGH CLINICAL REVIEWVEMLIDY CLINICAL REVIEW REQUIRES CLINICAL REVIEWVENCLEXTA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWVENTAVIS SOLUTI CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VERAMYST 27.5 MCG NASAL SPR LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONEVEREGEN 15% OINTMENT CLINICAL REVIEW REQUIRES CLINICAL REVIEWVERELAN PM CAP PELLE LOWER COST ALTERNATIVES VERAPAMIL EXTENDED RELEASEVERSACLOZ 50 MG/ML SUSPENSI LOWER COST ALTERNATIVES CLOZAPINE GENERIC VESICARE TABLET LOWER COST ALTERNATIVES OXYBUTYNIN/XL,TROSPIUM 20 MGVFEND TABLET/SUSPENSION LOWER COST ALTERNATIVES FLUCONAZOLE, ITRACONAZOLEVICTOZA INJECTION STEP THERAPY METFORMIN + ANY OTHER ORAL HYPOGLYCEMICSVICTRELIS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VIEKIRA CLINICAL REVIEW REQUIRES CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

VIEKIRA XR CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

VIGAMOX 0.5% EYE DROPS LOWER COST ALTERNATIVES OFLOXACIN, LEVOFLOXACIN OPHTH DROPSVIIBRYD LOWER COST ALTERNATIVES SSRI, VENLAFAXINE, BUPROPIONVIIBRYD ALL STRENGTHS LOWER COST ALTERNATIVES GENERIC SSRI, GENERIC SNRI, BUPROPIONVIMOVO TABLET LOWER COST ALTERNATIVES OMEPRAZOLE PLUS NAPROXENVIMPAT CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWVIRAMUNE XR 100 MG TABLET LOWER COST ALTERNATIVES GENERIC IR AVAILABLEVISICOL TABLET LOWER COST ALTERNATIVES COLYTE, GOLYTELY, NULYTELYVITAFOL NANO TABLET LOWER COST ALTERNATIVE USE MULTIVITAMINS W IRONVITAFOL ULTRA SOFTGEL LOWER COST ALTERNATIVES MULTIVITAMIN WITH IRONVIVAGLOBIN 16% VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


VIVELLE-DOT PATCH LOWER COST ALTERNATIVES ESTRADIOL TRANSDERMAL PATCHVIVLODEX LOWER COST ALTERNATIVE MELOXICAM, IBUPROFEN, ETODOLACVONVENDI INJ 650 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWVONVENDI INJ 1,300 UNIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWVOSEVI CLINICAL REVIEW REQUIRES CLINICAL REVIEWVOTRIENT 200 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWVUSION OINTMENT LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMVYTORIN TABLET LOWER COST ALTERNATIVES SIMVASTATIN, ATORVASTATINVYVANSE (BINGE EATING DISORDER) LOWER COST ALTERNATIVE SSRIs, TOPIRAMATEVYVANSE CAPSULE; (ADHD) LOWER COST ALTERNATIVES ADDERALL XR 20 MGWELCHOL TABLET/PACKET LOWER COST ALTERNATIVES CHOLESTYRAMINEWILATE INJ CLINICAL REVIEW REQUIRES CLINICAL REVIEW



WINRHO SDF 1,500 UNITS VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY




XARELTO TABLETS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXALKORI CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


XELJANZ 5 MG TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

XELODA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW, MEDICATION MUST BE OBTAINED FROM SPECIALTY PHARMACY

XENAZINE TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXERESE 5%-1% CREAM LOWER COST ALTERNATIVES ABREVA CREAMXIBROM 0.09% EYE DROPS LOWER COST ALTERNATIVES DICLOFENAC, KETOROLAC OPTH SOLUTIONXIFAXAN TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWXIGDUO XR TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXIIDRA DROPS CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXODOL TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENXOLEGEL 2% GEL LOWER COST ALTERNATIVES MICONAZOLE, CLOTRIMAZOLE CREAMXOLOX 10-500 MG TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENXOPENEX CONC 1.25 MG/0.5 ML LOWER COST ALTERNATIVES ALBUTEROL NEBULIZER SOLUTIONXOPENEX HFA 45 MCG INHALER LOWER COST ALTERNATIVES PROAIR HFA 90 MCG INHALERXOPENEX INHAL SOLUTION LOWER COST ALTERNATIVES ALBUTEROL NEBULIZER SOLUTIONXTAMPZA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,

USE MORPHINE ER 12 HOUR TABLETSXTANDI 40 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWXULANE LOWER COST ALTERNATIVE ORAL CONTRACEPTIVESXYNTHA 250 UNIT KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWXYNTHA 500 UNIT KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWXYNTHA 1,000 UNIT KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWXYNTHA 2,000 UNIT KIT CLINICAL REVIEW REQUIRES CLINICAL REVIEWXYNTHA 3,000 UNIT SYRINGE CLINICAL REVIEW REQUIRES CLINICAL REVIEWXYREM 500 MG/ML ORAL SOLUTI CLINICAL CRITERIA REQUEST MUST MEET ESTABLISHED CLINICAL

CRITERIAXYZAL TABLET LOWER COST ALTERNATIVES CETIRIZINE; LORATADINEYAZ CLINICAL REVIEW REQUIRES CLINICAL REVIEWZADITOR 0.025% EYE DROPS LOW COST ALTERNATIVE KETOTIFENZALEPLON 5 MG, 10 MG CAP LOWER COST ALTERNATIVES USE ZOLPIDEMZAMICET SOLUTION LOWER COST ALTERNATIVES HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIRZANAFLEX CAPSULE LOWER COST ALTERNATIVES TIZANIDINE TABLETS, CYCLOBENZAPRINE,

ORPHENADRINE, METHOCARBAMOLZARXIO SOLUTION CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,




ZATEAN CAPSULE LOWER COST ALTERNATIVES PRENATAL PLUS IRON TABLETZAVESCA 100 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZECUITY PATCH LOWER COST ALTERNATIVE SUMATRIPTAN TABS, INJECTION, NASAL SPRAYZEGERID OTC 20-1,100 MG CAP LOWER COST ALTERNATIVES OMEPRAZOLE; PLUS SODIUM BICARBZELBORAF TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZENZEDI TABLET LOWER COST ALTERNATIVES USE AMPHETAMINE, DEXTROAMPHETAMINEZEPATIER LOWER COST ALTERNATIVES PA REQUIRED USE HARVONI/EPCLUSA GENERICSZETIA 10 MG TABLET STEP THERAPY PRIOR USE OF STATINZETONNA LOWER COST ALTERNATIVES FLUNISOLIDE, FLUTICASONE NASAL SPRAYZETONNA NASAL AEROSOL LOWER COST ALTERNATIVES FLUTICASONE, FLUNISOLIDE NASAL SPRAYZIANA GEL LOWER COST ALTERNATIVES DIFFERIN GEL 0.1% OTC, BENZOYL PEROXIDE,

CLINDAMYCIN SOLUTIONZINBRYTA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZIOPTAN LOWER COST ALTERNATIVES LATANOPROST OPHTH SOLZIOPTAN OPHTH SOL LOWER COST ALTERNATIVES LATANAPROST OPHTH SOLUTION ZIPSOR 25 MG CAPSULE LOWER COST ALTERNATIVES USE NAPROXEN, DICLOFENAC, ETODOLACZIRGAN 0.15% OPHTHALMIC GEL LOWER COST ALTERNATIVES VIROPTIC 1% EYE DROPSZIRGAN OPHTH CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZOLINZA 100 MG CAPSULE CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZOLPIDEM TART ER TABLET LOWER COST ALTERNATIVES ZOLPIDEMZOLPIMIST 5 MG ORAL SPRAY LOWER COST ALTERNATIVES ZOLPIDEMZOLVIT 10 MG-300 MG/15 ML S LOWER COST ALTERNATIVES HYCET 7.5 MG-325 MG/15 ML S; LORTAB ELIXIRZOMIG 2.5 MG NASAL SPRAY LOWER COST ALTERNATIVES SUMATRIPTAN TAB/NASAL SPRAY, NARATRIPTAN TABZOMIG 5 MG NASAL SPRAY LOWER COST ALTERNATIVES SUMATRIPTAN, NARATRIPTANZOMIG TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEZOMIG ZMT TABLET LOWER COST ALTERNATIVES IMITREX, AMERGEZONALON 5% CREAM LOWER COST ALTERNATIVES HYDROCORTISONE CREAM 1%ZONATUSS LOWER COST ALTERNATIVES BENZONATATE CAPSULE 100 MG OR 200 MGZONTIVITY TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZORBTIVE 8.8 MG VIAL CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZORTRESS CLINICAL REVIEW REQUIRES CLINICAL REVIEWZORVOLEX CAPSULE LOWER COST ALTERNATIVES DICLOFENAC, NSAIDZOVIRAX OINTMENT, CREAM LOWER COST ALTERNATIVES ABREVA, ORAL ACYCLOVIRZUBSOLV TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZUPLENZ SOLUBLE FILM LOWER COST ALTERNATIVES ONDANSETRON ODT TABLETZURAMPIC TABLET CLINICAL REVIEW REQUIRES CLINICAL REVIEWZYCLARA CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZYCLARA 3.75% CREAM LOWER COST ALTERNATIVES IMIQUIMOD CREAM 5%ZYDELIG TAB CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEWZYDONE TABLET LOWER COST ALTERNATIVES OXYCODONE WITH ACETOMINOPHENZYFLO 600 MG FILMTAB STEP THERAPY FAILURE OF INHALED STEROIDZYFLO CR 600 MG TABLET STEP THERAPY FAILURE OF INHALED STEROIDZYMAXID 0.5% EYE DROPS LOWER COST ALTERNATIVES CIPROFLOXACIN 0.3% EYE DROPZYTIGA TABLET CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW,


ZYVOX TABLET/SUSP CLINICAL REVIEW REQUEST MUST GO THROUGH CLINICAL REVIEW


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